Confession: I experience feelings about clients during their therapy sessions, and I know plenty of respected colleagues who also do. We are human after all, and it’s part of the human condition to feel, particularly in relation to another.

feelings towards clients can include boredom, rage, repulsion, fondness and something akin to love or hate. They can be difficult to bear, but bear them we must because they contain vital information about the dynamics at play between our client and us. Our feelings might be understood cognitively, for example ‘I feel irritated by him’, or they could be experienced in the body, perhaps as an ache or a sickness, and can range from subtle to overwhelmingly powerful. I’ve been encouraged to acknowledge my feeling response to clients from day one of my psychodynamic training, but I’m aware that not everyone is comfortable with this. I’ve debated with counsellors who argue that it’s unscrupulous to have, let alone admit to, feelings about clients. I believe the contrary; that it is disingenuous to deny such feelings, and to do so is to miss a significant therapeutic trick that can lead to a deeper understanding about our clients’ worlds. In this article, I present the case for feeling our feelings, with a particular emphasis on those felt in the body. I illustrate my assertion that feelings are communicative, informative and invaluable therapeutic tools through the use of vignettes borrowed and disguised from my clinical experience.

Transference/countertransference Counsellors and therapists with a psychodynamic training might recognise what I’m talking about as countertransference, and that’s a good place to start. Countertransference is our response to the client’s transference, a phenomenon first suggested by Freud1to describe the way his patient, Dora, transferred her (sexual) feelings onto him. In essence, transference describes the way that clients relocate feelings about other people (unconsciously) onto the therapist. For example, a child client I’ll call Dotty presented differently during a recent session. She spoke to me more aggressively, threw a ball at me and walked out of the session early without saying goodbye. Because this was different from how Dotty usually presented, I understood that she was relating to me in the transference as if I were someone else. I was attacked verbally, physically and emotionally, most likely because Dotty felt attacking towards someone else. I discovered later that she had been let down by her estranged father, who had failed to take her out as arranged.Psychodynamically informed therapists believe that real-world relationships get re-enacted in the therapy room. In this way, the transference relationship helps to inform how the client relates to others and can identify patterns in their relationships. If Dotty had presented as aggressive and rejecting in every session, she would have illustrated something about her internalised relationships as rejecting and attacking. Usually she didn’t present this way, so I was able to recognise the shift as significant. The emphasis we put on transference, as a means of communication is one of the reasons why it is vital to maintain consistent boundaries. If something feels different, when everything else is the same, it is likely to be a transference communication.Countertransference is therapists’ feeling response to clients’ transference. This was initially perceived (by Freud) as a hindrance that should be analysed away. However, it has become recognised as one of the most valuable therapeutic tools that therapists have at their disposal. In the example above, Dotty invited me to re-enact a role by provoking me into feeling attacked. I did feel attacked, and I also felt hurt, confused, and ultimately rejected. It was my role to contain and process those feelings, by remaining thoughtful, and avoid taking up the position Dotty dictated, by either retaliating or trying to make things better. In the following session, I recalled aloud that the previous one had felt different. Dotty told me about her father and I remarked that it feels painful when someone lets us down and we might want to hurt them for hurting us. As therapists, ‘we do something like what a mother does, by trying to bear the feelings, and (we) hopefully process them and understand’.2Then, when the time is right, we can give those feelings back to our client, as I did with Dotty, in a more processed and manageable form. When a feeling is aroused during a client session, it’s important to determine its origin. For example, is the trigger something personal, such as being tired after a late night, or irritable because of a quibble with a colleague? Does it relate in an obvious way to what’s happening in the room, like feeling anxious in response to a client who is at risk? Feelings that cannot be readily explained are the most significant ones to recognise and work through.Feeling sickOften, feelings towards clients are located in the body and have no obvious trigger. Nathan made me feel sick. We met weekly in a GP surgery equipped with desk and swivel-type office chair. The smaller-than-average nine year old was mostly nonverbal in his communication, except for expletives that he bandied about indiscriminately. He was described as destructive and unable to learn, and I had been asked to provide a clinical opinion on whether Nathan might meet the criteria for (yes, you guessed it) attention deficit hyperactivity disorder (ADHD). Throughout the six-session psychotherapy assessment, Nathan rejected all play and art materials on offer, choosing instead to bounce up and down and spin around on the chair. I remember struggling to decide how to write up my assessment. I was reluctant to say that Nathan hadn’t engaged: he’d presented at every session and stayed for the duration. But all he seemed to do was swear at me and wear out the chair’s suspension. When I reflected on Nathan’s sessions, I acknowledged that I always felt nauseous and that on more than one occasion I’d felt as if I might actually vomit. I remember thinking that I just had to bear the feeling, which I likened to seasickness or a hangover, and wait for it to pass. It was clear to me that my feeling was a symbolic communication that belonged to Nathan. I wasn’t actually seasick or hung-over, but the feelings were no less overwhelming than if I was. Our feelings can inform us about the feeling state of clients who are unable or unwilling to put words to their own feelings. McDougall3called this ‘disaffection’ and used the term to describe individuals who have historically experienced overwhelming emotion.Nathan was a child in care, and I decided to liaise with his social worker to find out more about his developmental history. I learned that his mother was addicted to alcohol and had been using substances throughout her pregnancy. Nathan was premature, with a low birth weight. I assimilated this with what I’d observed: a boy who was small for his age and clumsy, had difficulty with learning, attention and social skills, and who ticked (some of) the boxes for ADHD. But informed by my feeling response, which I’d likened to a hangover, I was able to wonder about Foetal Alcohol Syndrome. If I’d denied or disregarded that Nathan made me feel sick, he could have been well on the way to misdiagnosis and medication.Feeling deadStanley was 13 and selectively mute when we worked together over a period of 18 weeks. He spoke not one word, yet the feelings he provoked in me were overwhelming. Every week, Stanley arrived on time under his own steam. He sat in the chair opposite me, his head dropped to his chest and his arms flopped to the sides. In the early sessions, I attempted to cajole him into engaging with art materials, music or clay, but this was my agenda not his. Like Nathan (like all clients), Stanley needed to engage in his own way. His breathing was slow and heavy, and often he slept. Once or twice he seemed to soil himself. I was struck by his capacity to wake himself up in the final minutes of each session, as if he’d developed a physiological timer, and certainly suggesting he had internalised the rhythm of the sessions. Stanley’s commitment to therapy was evident, but what was less apparent was what he needed from me. Being alongside Stanley was akin to the experience of being with a nonverbal infant. I was reminded of Bion’s concept of ‘maternal reverie’,4 which is the capacity to sense and make sense of what is going on inside the infant. With Stanley, I felt a heaviness in my chest that dragged down through my abdomen. I experienced pins and needles in my hands, which felt cold. I felt sleepy and sometimes struggled to keep my eyes open or my chin raised. And at the end of every session, when it was time to stand up and leave, I had difficulty doing so because my legs felt dead. As with a preverbal infant, Stanley lacked the capacity to verbalise his feeling state, nor could it be directly observed. But I felt it. In our ending review with Stanley and his adoptive parents, I shared something of my powerful experience of feeling heavy and dead. I pondered aloud about cold hands, pins and needles and numb legs being symptomatic of poor circulation, as if the blood had been drained from me. I contemplated also about the preverbal baby who finds alternative ways to communicate their bodily state and needs. I was mindful of the anal/potty-training stage of development but was careful too not to shame the adolescent in the room who, I was sure, had soiled. I wanted to share how powerfully Stanley had communicated with me through feeling states, which I interpreted as symbolic representations of an internal world made up of dead/ murderous objects and the reality of his lived experience.5I wanted him to know that I had understood something about what it might have felt like when, at 18 months old, he had witnessed his father stab his mother dead.Feeling the feelingsMany clients come to therapy with a sense of not-knowing – why they’re here, what they want, what the point is – in relation to therapy, as well as existentially. A good place to begin making sense of things with them is by helping to make sense of their feelings. Often when I wonder how my client feels in relation to something that’s happened, they tell me what they think. I asked Joni, aged 14: ‘I wonder what it felt like when she walked away from you.’ And she responded with: ‘I don’t think she could handle being in a relationship.’ So I asked again: ‘I wonder how that felt for you.’ And she recounted the break-up of her relationship with Laura. The story provoked painful recollections of adolescent break-ups, and the associated feelings of not being good enough, pretty enough, sexy enough. I felt my throat constricting as I persisted with wondering about Joni’s feelings until she finally told me: ‘I don’t know what you mean, how did I feel!’ This isn’t uncommon. Often clients don’t know how they feel. Often, they’ve never been asked, or learnt the emotional language to verbalise it. I asked Joni if maybe she felt something in her body when she spoke about Laura. She told me she felt her chest tightening and her throat constricting like she couldn’t breathe properly. She said she hadn’t realised that until I’d asked. I commented that it is hard to take a breath when we feel in pain or panicky. And then Joni began to feel understood and to understand her own feelings of abandonment and rejection. There is an interesting theory that any stimulus leads initially to a physiological feeling (such as increased heart rate, sweating, shortness of breath) and that our emotional feeling (such as joy, sadness, fear) is a secondary response.6In other words, the physical feeling comes first and the ‘feeling-feeling’ comes afterwards. This idea reminds me again of the preverbal baby, whose entire experience resides in its physical sensations and how they are understood and responded to by their caregiver. For infants whose emotional needs have been neglected, it is difficult to differentiate between physical and emotional sensations.7The body acts as a container in which individuals, quite literally, feel their feelings. In the therapy room, this can manifest most noticeably in clients who present with psychosomatic characteristics, which can be interpreted as the body’s way of ‘speaking’ emotion.7FormulationsWhen we engage in a dynamic relationship with another person, we can’t not be triggered to feel something. But it’s one thing to acknowledge the feeling response we experience towards our client and quite another to know what to do with it. Sometimes, my feeling informs what I say, as it did with Dotty and Joni. Other times, I might use it as a cue to gather more information, like with Nathan. Or, I might share my feeling response with the client and/or their family as I did with Stanley. The most important thing, always, is to process the feeling first, by reflecting in session, post session and/or in supervision. That way, whatever we decide to do will be thoughtful rather than reactive. I also use my feelings to inform formulations. A psychodynamic formulation is a hypothesis about what might be going on for a client, based on their presentation, behaviour, history and environmental influences, as well as their impact on me in the room. It’s what guides my work and informs what the young person might need. A formulation is not a diagnosis; I’d go as far as to say it’s much more than that. It’s not scientific or empirical, pragmatic or measurable. It’s a holistic interpretation, based on my felt sense of the client in the room. My feeling response is integral to my work as a psychotherapist. It’s how I sense and make sense of what is going on through the act of ‘reverie’, which, as Bion stated, is an act of faith in the unconscious process.4I think that sums up the process of psychotherapy quite well.References1 Freud S. Three essays on the theory of sexuality. Standard edition, volume 7. London: Vintage; 1905.2 Kegerreis S. Psychodynamic counselling with children and young people. London: Palgrave Macmillan; 2010.3 McDougall J. Theatre of the body: a psychoanalytic approach to psychosomatic illness. London: Free Association Books; 1989.4 Bion WR. Second thoughts. London: Heinemann; 1967.5 Stern DN. The first relationship. Massachusetts and London: Harvard University Press; 1977.6 Nummenmaa L, Glerean E, Hari R, Hietanen JK. Bodily maps of emotions. [Online.] Proceedings of the National Academy of Sciences of the United States of America; 2014. www.pnas.org/ content/111/2/646 (accessed 12 September 2018).7 Sidoli M. When the body speaks. London: Brunner-Routledge; 2000.

I’ve had plenty to say, in training and in print, about adolescent sexuality. I’ve contemplated ordinary sexual development, troubling sexualised behaviour and issues affecting young LGBT clients, with a particular emphasis on T. I’ve ventured into more challenging arenas by reflecting on adolescents who engage in bondage, dominance, and sadomasochism (BDSM) and/or Sugar-Daddying. This article ventures further still by considering adolescent sexual fetishes. In order to protect the anonymity of my clients, what I present here are amalgamations of therapeutic experiences with young people of various ages and genders, consolidated into four unidentifiable clinical vignettes. Working with this client group provokes a tension for me between developing a psychodynamic understanding of the sexual fetish, while employing an ethical need to maintain my clients’ safety. My hope in writing this article is that it will help other counsellors and therapists to reconcile such dilemmas in their own work with adolescents who engage in sexually fetishistic behaviour.

Sexual fetishes come under the broad spectrum of paraphilia, which includes sexual arousal in response to atypical objects, situations, fantasies or individuals. DSM-IV defined paraphilias as deviations or disorders. However, DSM-V, published in 2013, made a distinction between paraphilia and paraphilic disorder – and between fetish and fetishistic disorder – stating that behaviour should only be regarded as a disorder if it causes distress or dysfunction (1). An article in The Journal of Psychiatry and Neurological Sciences titled ‘Sexual Fetishism in Adolescence’ supports my clinical observations that fetishism usually presents in males and has typically begun by adolescence (2). Yet despite this, there is limited literature and much misunderstanding. The same (2013) paper declares that one boy ‘was able to admit his interest and behavior [sic] was unacceptable and shameful’; which I find shameful in itself. However, it is worth noting that psychiatrists had the option of defining homosexuality as a mental disorder up until 1986, twelve years after it was removed from the DSM. By this reckoning, it will be a long time yet until sexual fetishes are accepted as lifestyle choices rather than ‘unacceptable and shameful’ sexual perversions.

Sublimation

Michael was a well-presented, attractive young man who was thirteen when we worked together over a period of three months. He was a looked-after child in residential care following numerous breakdowns of foster placements and a failed adoption. Michael’s ‘unmanageable behaviour’ was cited as the reason his placements had failed. He had been in residential care for six months when we met, and seemed contained and relatively content. He told me that while he might appear normal, he was in fact abnormal because he masturbated most days. When I wondered why Michael defined himself as ‘abnormal’ and whether his masturbation bothered him, he said he was turned-on by wearing womens’ clothes and that this was the reason that each of his placements had ended.

Michael described feeling aroused by the sensation of women’s underclothes; items such as nightdresses, knickers or tights that he disposed of after he’d finished with them. He told me that he wrapped the garments around his abdomen, thighs, penis and sometimes his face and then masturbated inside them until he climaxed. The sensation of the fabric was important to him, as was the ability to be inside it. The thing that bothered Michael was his preference for femaleclothing – he insisted that he wasn’t ‘gay or trans’ – and because he highlighted this as his only concern, I was also curious about the significance of his object choice at a symbolic level.

Sigmund Freud first wrote about the significance of infantile sexuality in his 1896 paper, ‘The Aetiology of Hysteria’ (3). He suggested that the origins of sexual urges, impulses and desires, which he collectively termed ‘libido’, could be traced back to infancy. Freud proposed that childhood sexual impulses are often repressed, while those that are acted out can develop into [what he called] ‘sexual perversions’. In a later work, ‘Three Essays on the Theory of Sexuality’, Freud defined fetishism as the ‘unsuitable substitute for the sexual object’ (4).

My work with Michael focused on exploring the significance of his ‘substitute sexual object’. Unsurprisingly, we were able to trace its origins to early childhood when Michael was first taken into care. He remembered missing the ‘smell and feel’ of his mother and aching for her physical touch. We began to understand that Michael had recreated the maternal sensation he craved through sublimation of desire onto female clothing. If we consider libido more generally as physical gratification, rather than specifically sexual pleasure, it’s not such a leap to accept that the behaviour Michael relied on for comfort as an infant, was the same behaviour that drove his sexual desire as an adolescent.

Substitute objects

Reggie was a rough and tumble twelve-year-old who resembled a whirlwind in the therapy room and the wider world. His clothes were grubby, often ripped and he generally had cuts and bruises sustained either from falls or fights. He and his younger brother lived with their single mother who clearly had her hands full. It was difficult to engage Reggie in dialogue as he was often distracted and seemed unable to grasp the to-and-fro of conversation. His language was littered with expletives that seemed to spill out in a stream of consciousness that became the soundtrack to our sessions – ‘fuck, cunt, wanker, dick…’ in a singsong kind of way. Reggie and I played simple games together such as Snap and dominoes. He had an inability to ‘stay with’ – me or any activity – for long and seemed to have an unbearable fear of losing. Reggie repeatedly grabbed at his crotch and wiggled about in a way I couldn’t help notice. I think he wanted me to think of him as a male with a penis, which of course he was, and with potency.

A shift came about when, in one particular session, Reggie appeared to masturbate. At first I said nothing as he rubbed at his groin while we played a game of cards. His actions became more purposeful as he put his hand inside his shorts, and quite deliberately moved it up and down while singing a made-up song about ‘dicks’. Reggie was provoking me to react to his behaviour while his direct eye contact seemed to be saying ‘what do you think about THIS clever lady?’ Gaging my response felt crucial and I proceeded with caution by stating the obvious, ‘it seems as if you want me to notice something…’ Reggie continued to look me in the eye, while also continuing to simulate masturbation. I wondered aloud if he could tell me about what was happening with words. When he said nothing I ventured on and said it seemed to me that he was rubbing himself inside his shorts. We maintained eye contact and I wondered how long we would go on like this, while also trying to contain my internal sense of panic. Reggie pulled his hand slowly out of his shorts and with it came a fidget spinner, followed by another, and then a spoon.

Immediately what flashed through my mind were the numerous times he had attempted to take things from my room; dominoes, pencils, pebbles, by pretending to overtly secrete them down his pants. I realised now that I had under-interpreted his actions as a desire to take something of mine away with him. This may have been partly true, but I had missed the clues that Reggie had provided about where he was taking them; i.e. down his pants. It also made sense to me now that this usually happened at the end of sessions, during the ‘door-knob’ moment so that there was never time for me to comment or explore.

As with Michael, I was curious about the significance of Reggie’s ‘substitute objects’. I knew it was unlikely that he would talk with me about this, so I decided instead to talk to his mother. What I discovered was that Reggie had been secreting seemingly random objects in his pants for as long as she could remember. She shared examples of finding small toys inside his nappy, which he continued to wear into his fourth year. Like me, she hadn’t initially assigned any sexual meaning, but she agreed with my observation that, more recently, Reggie seemed to garner a sort of sexual satisfaction from his ‘habit’. In accepting that his sexual urges focused on inanimate objects, we were able to redefine his habit as a fetish. As Reggie’s mother elaborated, I had the sense of an addiction, and was mindful that the purpose of any addictive behaviour is to dispel painful feelings. I knew something of Reggie’s history. He was born into a traveller community and his teenage mother had relocated countless times. Reggie had witnessed both physical and sexual violence, as well as drug and alcohol abuse and had received no formal education.

The psychoanalyst Joyce McDougall wrote that ‘objects of desire perform the function of a drug’ (5) and we know that the function of a drug is escape from reality. Reflecting on Reggie’s sexual fetish in the context of his developmental history allowed us to assign meaning. Its purpose, it seemed, was to disavow overwhelming childhood experiences.While Reggie was unable to verbalisefeelings, it now seemed obvious that he could feel them. McDougall called this inability to put words to feelings ‘disaffection’ and used the term todescribe individuals who had experienced overwhelming emotion that threatened to breakdown their sense of identity. This fit with my sense of Reggie as a vulnerable little boywho wanted to present asa powerful, potent male. McDougall also wrote that disaffected individuals have ‘an inability to contain and reflect upon an excess of affective experience’ (6). By working with Reggie’s mother to better understand his behaviour, we were able to adjust our responses to him. At home and in therapy we shared our observations aloud with Reggie; ‘it seems you have put something inside your pants’ and demonstrated that we understood his motivation; ‘maybe it feels nice’. Over time, we elaborated further; ‘maybe it feels nice to do that when you’re scared or confused…’ Gradually the behaviour diminished, as Reggie began to feel less overwhelmed by his feelings and more contained by us. This piece of work demonstrates what can be achieved when therapist and family work together to contain a young person, even when the explicit trauma remains unnamed.

Fixations

Zion was a fifteen year-old looked-after child who had recently moved to a new placement when I met his foster carers for consultation. His previous placement had ended because the family had concerns about ‘sexually inappropriate conduct’. They described an ‘unhealthy fixation’ with their new baby grandson, and said that Zion seemed to be sexually excited by him. There had also been a number of incidents of finding Zion in ladies public toilets, which had resulted in the breakdown of several previous placements due to his ‘potentially predatory behaviour’. His new carers wanted my help to understand Zion’s behaviour so that they could support him and break the cycle of rejection. I encouraged them to talk to Zion in a non-condemnatory way and to hear what he had to say. It soon became apparent that Zion wasn’t sexually attracted to babies, but that had a fetish for babies’ nappies. And the reason he frequented ladies public toilets was to acquire them from nappy bins, which are still mostly missing from gents’ public conveniences. This came as a relief to the carers; Zion wasn’t a risk to women or babies, and it allowed them to think with him about how they could help him to satisfy his fantasy in a safe way. As with Reggie, this indirect working allowed Zion to feel contained and understood and his sexual fetish gradually gave way to more ordinary adolescent sexual behaviour.

Partialism

My work with Eric focused explicitly on his sexuality and sexual preferences. The eighteen-year-old had requested therapy to explore ‘issues with intimacy’ and concerns about his inability to maintain an erection, either alone or with another man. Eric had come out as homosexual aged fifteen. He had experimented sexually with girls during his early teens in an effort to fit in with his peers. This included mutual masturbation and oral intercourse, which left him feeling dissatisfied and inadequate. Once he was ‘out’, Eric started hooking up with men he met online in the hope of forming a relationship. Inevitably, the men he met wanted sex, which Eric declined because he was fearful about anal penetration and unsure about his preferences. Although Eric was frequently attracted to the men he met, he never experienced an erection during masturbation or digital penetration. And so the cycle of dissatisfaction and inadequacy that brought him to therapy continued. Things changed when he met Austin who was able to turn Eric on by cutting his thighs and abdomen. This felt double-edged for Eric, who was finally able to achieve sexual satisfaction, yet in a way that hefelt was perverse.

What struck me was both that Eric had subverted pleasure and pain, and also that sexual pleasure was assigned to non-genital parts of the body, which is sometimes referred to as partialism. I shared with Eric my concerns about safety, and assessed the risk as I would with any young person who self-injures (7). He assured me that clean blades were used and that the cuts inflicted were superficial. I encouraged Eric to describe the feelings elicited from being cut. He described an almost hallucinatory, trance-like state whereby all other senses were numbed except that of pleasure. In Theatre of the Mind, McDougall writes that the ‘perverse sexual act functions like a dream, a kind of hallucinatory creation of an alternative reality and serves as a solution to avoid painful internal conflicts’ (8). Eric’s internal conflict centred on his sexuality. He’d experienced disingenuous heterosexual flirtations, followed by a hesitant acceptance of his own homosexuality. It made sense that he had (unconsciously) redirected sexual pleasure away from the genital area, which he associated with confusion and sexual dysfunction. Once this was understood, Eric was less self-critical and more at ease with his sexuality.

Sexual behaviour in adolescence originates in infancy; where tensions are set up between primitive internal drives to comfort, soothe and satisfy, and external cues that disallow them. My work with adolescents supports the notion that ‘human sexuality is inherently traumatic’ (5), particularly for those struggling to make sense of their sexual preferences, including paraphilia. Very few present with an explicit wish to change their predilection, but most display an admirable desire to work with me to better understand it. To do this, we explore their developmental narrative through a psychodynamic lens. I share as much or as little of my interpretations as I think my client will find helpful. What is most reassuring for them to hear is that, thought about in context, their behaviour makes sense. This frees them up to make sense of it too and to accept it or let it go. (2509)

8. McDougall, J. (1982) Theatre of the Mind: Illusion and Truth On the Psychoanalytical Stage, Free Association Books, London

Letter to Therapy Today published April 2018

I’m all in favour of a debate and I welcome hearing and reading opinions that differ from my own; it helps me to challenge my existing beliefs, learn, develop and avoid getting stuck. What I didn’t welcome was the publication in the March issue of the three letters in response to ‘Putting gender on the agenda’ (News feature, December 2017).

The letter from Transgender Trend argues that contributors to the news article, of which I was one, ‘have no idea of youth culture’ – I beg to differ – and that ‘trans’ has become the highest-status identity’. Transgender is not about status and is not an identity choice any more than cisgender is. My extensive experience of working with ‘youth culture’ over the past two decades illustrates that transgender young people put up with a lot of ignorance and hate – no-one would choose that. The letter goes on to name and quote me as saying that parents who have had a son for 15 years and now have a daughter can find it mind-blowing. What I also said was that ‘I do my best to acknowledge how difficult it can be for them to support their child while managing their own feelings of confusion and loss.’ Transgender Trend does the opposite: their raison d’etre is to campaign against supporting gender diversity in young people. The letter, and our organisation, failed to mention that.

The letter has been removed from BACP’s website but the proverbial horse has bolted all over social media. The vast majority of comments on Twitter rallied against BACP for their apology rather than Transgender Trend for voicing their non-affirmative stance. Tweeters shared ignorant and anti-trans opinion, contrary to our code of ethics and the MoU. Many were BACP members working with CYP who must have felt vindicated in their prejudicial views following the publication in their professional journal of anti-trans propaganda. I worry for young people seeking support, as it is evidently a lottery as to which side of the ethical/affirmative fence their counsellor resides.

Another of the letters was written by a BPC/UKCP member who shares the position and values of Transgender Trend. He has re-tweeted both letters repeatedly arguing that they contain ‘irrefutable truths’. On the contrary. His letter states that ‘Self-identification as trans may seem to offer a magical solution to’ … ‘issues related to emerging sexuality, family break-up, social isolation, autistic traits, self-harming and/or traumatic memories’. Really – a magical solution? I find it deeply concerning that a registered psychotherapist holds such a viewpoint. The letter also states, erroneously, but as if it were fact, that ‘medicalisation with hormones and surgery [is the] default treatment’. Any transgender person who has decided to transition (and many do not) will tell you that the long road to transition is paved with assessments, therapy and questions. It concerns me that BACP have failed to remove and apologise for this contribution as they did the other. Yet the writers of both share the same non-affirmative stance and say they specialise in offering therapy to young people who identify as transgender and training to those who work with them.

The only letter from a bona fide member of BACP makes some valid points. I agree; it is not ok to compare a young person identifying as transgender – a reality – to one identifying as a panda – a fantasy. However, she goes on to state: ‘The Tavistock takes a controversial and extremely conservative line’ [in]‘…never’ giving up hope that the […] trans person in front of you might not actually be trans’. This is not my experience of supporting young people with community-based psychotherapy alongside their treatment from Gender Identity Development Services (GIDS) and nor is it theirs.

I don’t know why Therapy Today decided to publish two anti-trans letters from non-BACP members. I accept that letters are published with a disclaimer that they contain the views of the author, not the organisation, but we’re talking about a code of ethics here, not merely a difference of opinion. My hope is that BACP will take better care of us and our clients in the future, regardless of gender.

What's the harm?

It’s vital to understand self-harm as a way of coping, not as a suicide bid, writes Jeanine Connor

When was the last time you knowingly did something harmful to yourself – smoked a cigarette or nicotine substitute; drank a glass of wine over the recommended allowance; swallowed a couple of paracetamol above the prescribed amount; took a recreational drug; skipped a meal or binge ate? Usually we do these kinds of things because we think they’ll change our mood in some way by helping us to unwind, de-stress, or relieve psychological pain. On occasion, we might do things we know are harmful in order to manage our emotions or dissociate from them. Is this self-harm?

Most people think of self-harm in terms of cutting or burning and associate it with adolescent girls, sometimes as a way of ‘acting-out’ and sometimes following a ‘copycat’ trend. All too often it’s labelled as ‘attention-seeking behaviour’ and is misunderstood or dismissed. Self-harm is far more complex than these simplistic stereotypes suggest, as I hope this article will illustrate, and it is prevalent across all genders, cultures and age groups. If we are to work with it, it is important that we counsellors and therapists are clear in our own minds about what we understand by self-harm, as this will influence our clinical work from contracting to discharge, as well as inform decision-making around safeguarding and disclosure throughout the period of therapeutic engagement.

In this article, I draw on a number of definitions of self-harm, mostly expressing or derived from a medical, diagnostic model even if they are written in lay language. While I do not necessarily endorse these definitions, they provide a valid starting point for a critical exploration of self-harm and how we can work with it safely, appropriately and therapeutically. They also remind us how our colleagues in mental health and medical settings may view it. As I work almost exclusively with children and young people, the clinical examples I include are from the adolescent age group, although similar models of working can be applied whatever the client’s age. These examples are amalgamations of multiple client experiences rather than identifiable individuals.

Motivation

NHS Choices, the public-facing health information website, defines self-harm as ‘... when somebody intentionally damages or injures their body... usually as a way of coping with or expressing overwhelming emotional distress’.1 This is uncontentious but restricted and does little to inform our understanding or treatment of self-harming clients.

The online Medical Dictionary is more nuanced, defining self-harm as: ‘The deliberate infliction of damage or alteration to oneself without suicidal intent, in particular by those with eating disorders, mental illness, a history of trauma and abuse e.g. emotional or sexual abuse – or mental traits such as low self-esteem or perfectionism.’2

Both these definitions lay stress on ‘intentional’ or ‘deliberate’ which for many, have judgmental resonances. While there has been a welcome shift away from ‘deliberate self-harm’ (DSH) in some settings, the new language of non-suicidal self-injury (NSSI), which feels less condemnatory, is taking a while to become fully embedded.

I contest the use of the word ‘alteration’ contained in the Medical Dictionary definition, as would most of my clients. I have debated with counselling and psychotherapy colleagues whether tattooing, piercing, ear stretching or cosmetic surgery are forms of self-harm. To me, even people who go to seemingly extreme lengths of piercing and stretching to alter their body and/or face are not demonstrating self-injury. The crucial difference is the motivation, which for these individuals is to enhance and embellish their bodies rather than harm them, however extreme their methods might seem.

I also find problematic the suggestion that self-harm often accompanies eating disorders (although, confusingly, eating disorders are sometimes described as a form of self-harm3), mental illness, or a history of trauma and abuse. I think that this definition perpetuates an increasing trend towards pathologising behaviours that, seen from the individual’s perspective, may be regarded as an understandable response to an unbearable situation. Pathologising suggests that someone who self-harms is ill. Some people with a diagnosed eating disorder or mental illness might self-harm and the behaviour could be an expression of trauma, but that is not the place from which to start the conversation. It is helpful to note that the National Institute for Health and Care Excellence (NICE) states explicitly that: ‘Self‑harm is not used to refer to harm arising from overeating, body piercing, body tattooing, excessive consumption of alcohol or recreational drugs, starvation arising from anorexia nervosa or accidental harm to oneself.’4

I considered this definition useful in my work with Dan, a 19-year-old student who came to me for psychotherapy because of problems with intimacy. He was an unconfident, shy young man with lots of visible tattoos and enlarged earlobes through stretching. A couple of sessions into therapy, he arrived with deep scratches on his face, and told me he got them when he was drunk but couldn’t remember how. Later, he admitted that the scratches were self-inflicted, and over the following weeks his visible injuries became more extreme. He arrived at one session with a deep wound on his cheek having intentionally cut himself with a razor blade. Over several months of therapy, we worked through Dan’s hatred of his appearance and ambivalence about his sexuality. We disentangled the ‘alteration’ – tattoos and ear-stretching – from the ‘self-injury’. We explored the meaning of Dan’s behaviour in establishing his identity and I tried to encourage him to self-harm safely and helped him to find healthier and non-violent ways to express his emotions.

Ask the question

The Mental Health Foundation defines self-harm as: ‘... a wide range of things that people do to themselves in a deliberate and often hidden way’.5 I think it is a mistake to think of self-harm as often hidden – in my experience it may be selectively hidden, in that it may be concealed from parents, peers, partners or professionals, or the individual might self-injure on a part of their body that isn’t readily visible to others for a multitude of reasons.

This definition also states that, ‘in the vast majority of cases, self-harm remains a secretive behaviour that can go on for a long time without being discovered’. The chances are then, that some of our clients may be self-harming and we don’t even know it. Whether they disclose or not is up to them, but I think it is also up to us. As with any subject that is remotely taboo, clients pick up on cues from us about what is ok to talk about. When I’m working with someone who presents with low mood or anxiety – which is almost every young person I work with – I always enquire about self-injury. Most tell me they are hurting themselves, or have done so at some point in the past. If you don’t ask the question, you might be sending a message that you are uncomfortable talking about it and therefore your client will be too, thus perpetuating the secrecy.

When I asked, 12-year-old Gita told me that she had been self-harming since she was nine. I asked if she could tell me what she did, in as much detail as she felt comfortable to share. She was embarrassed and said she had never told or shown anyone before because she didn’t want to be accused of attention-seeking. I hear this lot. I said I didn’t need to see unless she wanted to show me, which she didn’t. She explained that she used the flat side of a scissor blade to graze the upper parts of her thighs. She had never broken the skin or caused bleeding. As we talked further, I began to understand that Gita had been struggling in silence with overwhelming emotional distress that she felt powerless to control. She was academically successful and popular at school, but had buried the pain of her parents’ separation and become isolated and depressed. Her mother was dealing with her own grief following the end of her marriage and the death of her father. Gita did not want to add to her mother’s distress or make her feel responsible for her unhappiness, and so she kept her feelings hidden. For some people who self-harm, the act of injury is what helps. Over time, we worked out that the important thing for Gita was not hurting herself physically per se, but having the power to stop the physical pain. Gita couldn't stop the emotional pain, but it helped her that she could stop the physical pain, and to be able to do that, she had to inflict it.

Gita was academically successful and popular at school, but had buried the pain of her parents’ separation and become isolated and depressed. Her mother was dealing with her own grief following the end of her marriage and the death of her father. Gita did not want to feel like she was adding to her mother’s distress or making her feel responsible for it and so she kept her feelings hidden. I meet so many girls like Gita who have concealed their psychological pain and the physical harm they have relied upon to manage it. They are the antithesis of the ‘attention-seeking’ adolescent. I helped Gita to uncover the pain and put her feelings into words; a painful process, but with it came relief from no longer having to hide a secret that felt shameful and, in time, Gita no longer felt the need to rely on self-injury as a way of managing her emotions.

Self-poisoning

The NICE definition of self-harm includes: ‘... any act of self‑poisoning’4 and I think this inclusion is useful. I have worked with young people who self-poison by inhaling gas or aerosols or swallowing toxic substances. Their motivations are different from those of young people who take recreational drugs and it is important, therefore, to establish the meaning behind the act of self-poisoning – to cause harm or to get high – in the same way that it is important to distinguish alteration of the body from self-injury.

Robert was 14 and had just been excluded from school for the third time when he was referred to me for psychotherapy. He found it difficult to settle physically or mentally. His mother was emotionally distant, and was self-medicating for depression with alcohol. Robert had low self-worth and had internalised the script that he was ‘useless like his father’, who was serving a prison sentence for aggravated burglary. Robert was aggravated too, and had a tendency to aggravate people around him. Over six initial assessment sessions, I discovered that Robert had worked hard to keep his family narrative a secret and that he felt enormous shame when people found out. He had presented as angry and aggressive throughout primary school and had now turned that aggression on himself. When I asked about self-injury, Robert told me he had, in the past, used aerosols to burn his skin. This started out as a dare but had developed into something more like self-punishment. He then began inhaling aerosols in order, he said, to ‘feel dead’. We began to understand this as a means of temporary escape: Robert didn’t want to die; he wanted some relief from the emotional pain of his experiences. Self-poisoning was a way to numb that pain by replacing it with another.

Non-suicidal self-injury is not, and never has been, listed as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the guide developed in the US and routinely referred to by medical professionals throughout the UK. It is, however, included in a new category in the latest edition, DSM-56, called V-codes, which describe ‘other conditions or problems that may be a focus of clinical attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder’. (Of note, V-codes also include parent-child relational problems, relationship distress and academic/educational problems.) The new V-code categorisation explicitly recognises that NSSI (and other V-codes) are ‘relational problems requiring relational solutions’, rather than mental disorders with the stigma this implies.7 While a primary function of inclusion in the DSM in the US is access to medical treatment, the new coding system provides a welcome shift away from medicalising behaviour and encourages professionals to think differently.

DSM-5 definesNSSIas ‘the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned, including behaviors [sic] such as cutting, burning, biting and scratching skin as a way of coping with difficult emotions’. This is the most inclusive of all the definitions I have found, as it addresses the what, how and why of self-harm, as well as what it is not. I think the ‘socially sanctioned’ part helps distinguish piercing, tattooing etcetera from self-harm, as does the NICE definition, and DSM-5 also highlights the distinction between self-harm and suicidal intent. Self-injury is often a means of staying alive, a bid for survival, not death, although it may be accompanied by suicidal thoughts and persistent self-harm can be a risk factor for suicide.

Lucy was 13 and had a history of risky behaviour, including serious self-injury, sexual promiscuity and absconding when she was referred to me for psychotherapy. She was small, heavily made-up and fragile-looking. To me, she seemed empty inside, like a china doll. She said she hated her ‘no-good’ mother and described her father as a relentless bully who ‘doesn’t know when to stop.’ Shortly after we started to work together, her self-injury escalated. When her mother tried to make the home safe by removing any sharp implements, as I had insisted, Lucy smashed a window and used the glass to cut herself so deeply that she had to have stitches. She pierced her face with a compass point and the wound became infected. She refused to eat or wash. She dyed her hair blue. She had unprotected sex with older men ‘because they wanted to’. She constantly said she’d be better off dead, although she had no suicide plan or intention to kill herself. I wondered about the escalation in Lucy’s self-harm and what the attacks on her body might be about. I understood the uninhibited flaunting of her physical injuries as an attempt to draw attention to her distress. It felt important to show her that I understood that these visible displays were communicating pain that she was, as yet, unable to verbalise. I didn’t want her to perceive me as either intrusive father or useless mother; I needed to ‘hold’ Lucy (psychologically) and proceed at her pace. My being able to bear her behaviour allowed Lucy to finally disclose that her father was sexually abusing her. We later came to understand her attacks on her own body as symbolic attempts to eradicate the intolerable memories of the trauma she had endured. They might also have illustrated her attempt to control her feelings of murderous guilt and rage towards both her abusive father and her mother, who failed to protect her, by displacing them onto herself.8 My work with Lucy came to an abrupt end when she was removed from her family for her own safety.

Disclosure

With Lucy, I had no reservation about sharing information with the statutory authorities about her self-harm and her disclosure of abuse. But it is rare that I need to raise self-harm as a safeguarding concern, even though most of my clients self-injure. When I contract with new clients, I tell them that, if I am worried about their safety I might need to talk to someone else about it, but that I will always talk to them first. If a client tells me they are self-harming, I keep in mind the DSM-5 definition – that the behaviour is ‘a way of coping with difficult emotions’, and that it is different from suicidal intent.9 I explore their means and motivation by asking what, how and how often they injure themselves. I tell them that it is not for me to either condemn or condone their behaviour, but that my role is to understand what they are doing and why, and to work with them, and their family if it’s appropriate, to keep them safe. I usually say that I have met lots of young people who self-harm, to demonstrate that I can bear it, but I always emphasise that I know it means something different for each of them. I tell them that I want to understand what it means for them, to reassure them that I am making no assumptions.

For me, risk assessment is not a one-off event; it is entrenched in every session of psychotherapy. It includes an appraisal of each client against what might be ordinary, age-appropriate behaviour within their family and social context. Assessment is also informed by organisational protocols and procedures and professional ethical guidelines, as well as by my own clinical experience and instinct. The NICE guideline on self-harm provides a helpful framework for working with clients safely. For clients who repeatedly self-harm, NICE recommends offering advice on how to treat their own superficial injuries and on harm-minimisation, for example by using clean blades and antiseptic products, rather than trying to stop them from doing it; which is seldom effective.4

In my work with both Dan and Robert, I understood their self-injury as an expression of distress rather than suicidal intent, and embedded in our sessions suggestions for ways they could self-harm more safely. With Gita, I didn’t share with the statutory authorities or with her family her disclosure of self-injury, despite her young age, but nor did I collude with her secrecy. I encouraged her mother to acknowledge and ‘bear’ her daughter’s feelings of grief as separate from her own.

If we continue to monitor the level of risk, we should be able to hold our clients’ distress. Putting words to their pain, in my experience, leads to a reduction in the reliance on self-injury, whatever the client’s age.

8. Fonagy P, Target M. Towards understanding violence: the use of the body and the role of the father. In: Perelberg RJ (ed). Psychoanalytic understanding of violence and suicide. London: Routledge; 1999 (pp51–72)

The T word

Jeanine Connor addresses difference in the form of sexuality and gender,
including transgender, and invites us to work out how we will welcome all such
diversity into our counselling rooms – by informing ourselves and by leaving behind
any fearful or confused mentality around young LGBTQ clients that might lead us
unwittingly to withdraw from them therapeutically

The language of gender and
sexuality

The
acronym LGB (lesbian, gay, bisexual) first entered common parlance during the
1980s. Since then, it has been broadly accepted that sexuality cannot be
reduced to homo- or hetero- sexual. Gender too is less likely than it once was
to be defined in binary terms and LGB was extended a decade later to reflect
this, incorporating T for transgender. The acronym has since been developed
further to include Q, for queer or questioning, depending on who you ask, and
sometimes + to incorporate asexual, pansexual, transsexual, intersexual,
intergender and other sexual or gender identities excluded from the original
abbreviation. There are some references on social media to LGBTTTQQIAA but that seems much
too nonsensical for most of us to fathom, both inside and outside of the LGBT
community. Suffice to
say, the terminology can be a bit baffling, with the potential to plummet into
political correctness pitfalls ever-present. If in doubt, I suggest sticking
with the basic four or five letter acronyms (LGBT and/or LGBTQ). Confusion
aside, this new language recognises difference and brings with it a level of acceptance.
If people of various gender and sexual identities were not recognised, there
would be no need for the appellations. But with everything so fluid, including
sexuality and gender, how can we, as counselling professionals, ensure that we
retain a firm footing and work candidly with young people who present with
issues relating to their gender and sexuality?

I am on
record as saying that sexuality is the
biggest issue for adolescents and pre-adolescents and I maintain that its
exploration takes up many a therapeutic hour. Sexuality is a broad church,
incorporating questions about physical development and intercourse, intimacy
and relationships, normalcy and perversions, gender, transgender and various
sexualities. Younger children (7, 8, 9 year olds) bring questions about their
bodies and other peoples’ bodies, as might be expected, but I also get asked
about the factual stuff by mid/late teenagers, the age group that are presumed
to know it all already. But how can they
know if they have not had a thoughtful parent or parent figure to ask and
reflect with and if their only points of reference are sneakily looked at porn
and ill-informed playground banter?

Rethinking gender fluidity

Adolescents
also bring issues around first sex, safe sex, pornographic sex and issues
around sexuality and gender variance. The latter is a more recent addition to
the list of ‘things to take to therapy’ and according to the Tavistock and
Portman, there has been a doubling of referrals to their specialist Gender
Identity Service (GIDS) which offers support to transgender and gender variant young
people under the age of 18 (1). Many counsellors are struggling to comprehend
this shift. A colleague was incredulous when his teenage client said he identified
as gender-fluid. The counsellor thought this was a ridiculous statement and
told me that gender cannot possibly be fluid; we are either male or female. I
agree that gender fluidity can be a challenging concept, particularly when it
jars with one’s own personal and perhaps religious beliefs, as in my
colleague’s case. But I’ve met numerous adolescents who identify this way, or
as transgender or gender variant, and in each case have explored what it means
to them. I’ve shared some of my clinical experiences in this journal previously
(2). My aim in the current article is to reflect upon the cultural shifts and
theoretical models that are informing my work. Some psychologists have
suggested that sex and gender should be conceptualised, not as switches that
point this way or that, but instead as a series of adjustable dials. Thought
about this way, sex is a continuum and gender a spectrum. Neither are
either/ors. These theoretical dials affect both nature and nurture. They
influence hormone levels and development in utero and at puberty, as well as personality
traits, and social, historical and cultural factors (3). The dials not switches
model supports the notion that gender identity is less likely to be entirely
male or entirely female and more likely to be something in between; perhaps something
more akin to gender fluidity. But my colleague’s explanation, the only one that
fit with his own sensibilities, was that gender fluidity is the latest fad. While
I disagree, I acknowledge that up until a few years ago gender issues rarely
entered the therapy room. To put this into perspective, transgender and gender
variance remains relatively uncommon. While referrals to GIDS have doubled,
they still only account for 0.01% of the population. The average age of referral
is fourteen and the service has witnessed an increase in referrals of natal
females; i.e. young people assigned female at birth (1). So if it is not the
latest fad, I wonder how we can explain the changing zeitgeist.

Cultural influences

There is
no doubt that the media plays a part in influencing the content of therapy. The
lasting legacy of ‘erotic’ literature aimed at women, euphemistically described
as ‘clit-lit’ has been more open discussions about bondage, domination and
sadomasochism (BDSM), as well as choice, control and rape. Meanwhile, soap
operas such as Hollyoaks, documentaries including Girls to Men and Transgender
Kids, as well as discussions and dramatisations on Radio 4 have brought gender
identity and gender reassignment into mainstream consciousness. Once these
issues have been evoked and emotions conjured, young people have limited options
about what to do with them. Many families feel embarrassed or ill equipped to discuss
sex and gender identity with their children or they leave it too late, not
through neglect, but through ignorance about what’s really on their minds. Formal
sex and relationship education is sketchy at best with many teachers afraid to
talk about sex with their students for fear of seeming provocative or
encouraging illicit activity. I think it will be a long time before gender variance
makes it onto the mainstream curriculum. But, like other apparent taboos, it
has made it into the therapy room already. Some young people perceive their
therapist as their only reliable source of information and for them counselling
provides a safe space for questioning and exploring issues to do with sexuality
and gender identity. Others are less fortunate.
Numerous professionals tell me that their clients never talk about sex
or gender, which conveys more about the counsellors’ lack of preparedness than
their clients’ issues. I am in no doubt that young people pick up on adults’
discomfort and censor what they share, repressing their thoughts and ending up feeling
more shameful than they did before.

Levels of engagement

In my
experience of working with young people, in various settings over two decades,
sex and sexuality have remained top of their most talked about list. My
clinical experience suggests that merely adopting a stance of unconditional
positive regard doesn’t cut the mustard. Young people want to experience a
connection and often that involves provoking a reaction. I can recall one
particularly revealing session with a sixteen-year-old girl who described to me
her fantastical carnal exploits in graphic detail. She identified as gender
fluid and pansexual meaning, she said, that her identity and sexual attractions
were not determined by biological gender. I listened quietly and nodded
attentively as she became increasingly animated. I didn’t question or comment.
I tried not to judge, challenge or condemn. My experience was limited in this
arena and I did what I thought a good therapist should do; I adopted a neutral
expression and said nothing until eventually she yelled at me to ‘stop fucking
nodding.’ That client taught me, with a verbal slap in the face, that it takes
two to tango, to fuck and to engage in therapy. People tell me they are
intimidated by adolescents and are afraid to talk to them about sex. I can see
why. Adolescents are overwhelmed by intimidating feelings, frequently to do
with their sexuality, and sometimes those feelings spill out.

The legacy of MoU

Our
society has thankfully progressed from a time when homosexuality was perceived
as illegal, taboo and/or a psychiatric condition in need of cure by medical
intervention or talking therapy. It seems we are a bit behind in our attitude
towards gender variance. The Memorandum of Understanding (MoU) in relation to
working with sexual diversity was signed by the British Association for
Counselling and Psychotherapy (BACP) in January 2015. The organisation also
lent its official support to the Royal College of Psychiatrists declaration on
sexual orientation which states that the diversity of human sexualities is
compatible with normal mental health and social adjustment (4). In
addition, BACP states that it opposes any psychological treatment such as reparative or conversion
therapy … based on the premise that the client/patient should change his/her
sexuality (5). However, BACP heard that the MoU was counter-productive to many counselling
professionals, who became anxious that providing therapy to clients with gender
and sexuality issues might be perceived as attempts at conversion. I frequently
hear evidence of prevailing anxiety from professionals who are fearful of
taking on transgender clients. I had a long debate with someone recently who
told me that his biggest fear was that a client would opt for gender
reassignment surgery as a result of counselling. His fear was not that he would
be accused of attempts at conversion or reparation, but instead appeared to be that
he might actively promote transgender. The counsellor’s fear is based on
ignorance; a very small number of transgender people opt for surgical
reassignment, with or without counselling. It surprises me that colleagues are
able to manage the risk and uncertainty surrounding clients who have eating
disorders, deliberately self-harm or contemplate suicide, where the worst case
scenario is loss of life, yet they feel overwhelmed by transgender. Are they
responding to fear of the unknown, or is the potential of transgender perceived
as a fate worse than death?

I cannot
know how counsellors and psychotherapists managed their anxiety prior to the
MoU in 2015, but I can assume there was a heavy dose of denial and avoidance. However,
once acknowledged, BACP’s response was to commission an article about how counsellors and psychotherapists
work with LGBTQ (Q for questioning in this instance). The results were
published in an article titled ‘I
think I’m gay… can you help?’(6). My own interview for the piece provoked
thoughts about my work with transgender and highlighted the lack of specialist
training. The article was well researched and covered a wide range of
experiences of working with sexuality, but it felt like a hark back to 1980s
LGB. The T word was conspicuously noticeable by its absence.

We will inform ourselves

So where
does all this leave those of us who are keen to develop our learning and
welcome all sexualities and genders into our counselling rooms? It leaves some
fearful and avoidant and many confused. As a profession, we are doing a
disservice to clients (or potential clients) who identify as transgender,
gender variant or questioning. While some of us are keen to learn, it is
unethical to rely on our clients to teach us (7). We have to be proactive. We
have to seek out knowledge and education from reliable sources and make
referrals to specialist services. GIDS is stretched. Currently there are just
two clinics in the entire country; one in London, the other in Leeds. They
offer assessment and treatment to young people under 18. Some assessments lead
to a formal diagnosis of gender dysphoria, where identified gender is contrary
to gender at birth, but most do not. It is interesting to note the change in
diagnostic label in DSM-V from gender identity disorder to gender dysphoria
(8). Its continued inclusion in the
diagnostic manual is, in part, to facilitate access to medical intervention. In
the USA, treatment requires insurance, which requires diagnosis. In the UK too,
private and public health care providers often rely on a diagnosis to inform an
appropriate care pathway. The newer diagnostic label also aims to alleviate the
implication of ‘disorder’ and is therefore less stigmatising and more
accepting, rather like the extended acronym LGBTQ.

Where
appropriate, GIDS can offer an endocrinological assessment to explore hormonal
and chromosomal characteristics. In some cases they can prescribe hormone
blockers to delay the onset of puberty. This is a fully reversible medical
intervention which affords the young person time to explore their gender
identity without experiencing the physiological changes associated with puberty,
which for gender variant or questioning young people can be intolerable. However,
GIDS stress that family and early developmental experiences are significant
contributing factors and that adult gender identity has its roots in early childhood
(1). The primary aim of the service is to explore family relationships and ease
emotional, behavioural and relational difficulties. The team offers professional consultations,
individual and family psychotherapy, parent groups and groups for young people,
often alongside local specialist Child and Adolescent Mental Health Services (CAMHS).
In other words, much of what they do is what we all do in our work every day –
assess, explore, support and reflect, by offering therapeutic interventions to
children and young people alongside direct or indirect work with the family.
This is what counsellors and psychotherapists are equipped to do and is what we
do well. So there is nothing to be afraid of.

Conclusion

Our world
is ever evolving. Young people are exposed and have easy access to more varied
and more extreme social influences. They are bombarded with images 24/7
dictating how they should look, feel, behave and have sex. They are under
constant scrutiny. They grow up fast and display signs of physical development
younger than ever before. Onset of puberty has decreased with many girls
showing first signs of sexual development at eight. Numerous theories have been
posited for this including diverse factors such as nutrition, pollution, the
absence or presence of fathers, increased affluence and over-exposure to
television (9). Meanwhile, experienced counsellors and psychotherapists in
young people’s services are an ageing population and many are out of touch. When
I mentioned this article to a colleague he had no idea what LGBT meant. This
unawareness is astounding, but not uncommon. Our own adolescence was poles
apart. Homosexuality was not decriminalised until 1967. The age of homosexual consent
only lowered to sixteen in 2001. For us, sexual development happened later.
There was no Internet, no same-sex marriage and no awareness of gender
variance. I’ve said it before but will keep banging the same drum; we owe it to
the younger generation to keep up. We must
inform ourselves (10).

Keeping up with our clients: a response to the new ethical guidelines

‘My foremost aim is to promote the client’s wellbeing and protect them from harm. For me, these are the guiding principles of my work and for my clients that is good-enough’

When was the last time you read
the BACP Ethical Framework? In my experience, formal documents such as these
are read on a need to know basis; something goes wrong, or has the potential to
go wrong, and members turn to an official lodestone for succour. According to
Andrew Reeves, BACP Chair, the revision of the Ethical Framework is in part a
response to ‘scandals and service
failures in health and social care that have inflicted significant harm’.
So it too could be described as a reaction to things gone wrong, or an attempt
at reparation, or an effort to develop our learning within the wider social and
political context, and an endeavour to ensure that things go less wrong in the
future.

‘Our commitments to clients’
serve as a reminder that our overarching aim is to do good, not harm, and there
are some interesting amendments. Previously, we were committed to ‘alleviating personal distress and suffering’
whereas now we are committed to alleviating the ‘symptoms of’ personal distress and suffering. I facilitated a
training day about mental health and asked participants to respond to the statement
‘I see it as my role to cure my client’s symptoms’. The unanimous consensus
amongst the forty BACP registered counsellors was a shared discomfort with the
words ‘cure’ and ‘symptoms’, both of which were initially perceived as pathologising.
But there was motive to my mischief. As I encouraged further consideration of
the statement in small groups, I witnessed a gradual shift in perspective. Most
counsellors remained uncomfortable with ‘cure’ which developed into something
more like ‘alleviate’. As their explorations continued, I observed less abstract
thinking and a greater reflection on tangible clinical experience. One counsellor
spoke about a client he’d been working with for many months who had presented
for counselling with chronic anxiety and social phobia. He had been unable to
maintain a personal relationship or hold down a job for most of his adult life
and had fallen into a state of depression following the death of both parents.
The counsellor admitted an initial urge to make things better for his client; a
desire to cure him. On reflection, he acknowledged the fact that while he could
never hope to relieve his client’s pain and suffering completely, he had
noticed a lessening of the symptoms that initially brought him to counselling.
With the support of the group, he was able to reflect on the work, which up
until now, had felt hopeless, and reframe the counselling objectives. As a
result, he would return to the counselling room with an increased robustness
that would feel enabling for his client. The exercise had achieved its aim of
bringing alive our commitment to alleviate the symptoms of distress and
suffering in an authentic and meaningful way. If time had allowed, it would
have been pertinent to replicate this application for each of the commitments
outlined in the ethical framework. This would be valuable CPD.

The new framework states
that well-founded ethical decisions should be strongly supported by one or more
of six ethical principles; trustworthy,
autonomous, beneficent, non-maleficent, just and self-respecting. In my
experience, the most difficult dilemmas arise when there is an impasse between two
or more of these principles. A common example from work with young people is of
requests for information. Parents and guardians are commonly asked to provide
pre-emptive consent for professionals to share information about their children’s
development, education, health and social care. What this means is that an
adult with parental responsibility may have consented to information sharing
when their child first accessed a service. In reality, this might have been
some considerable time prior to the current involvement and/or may have been
contrary to the child’s own wishes. Medical professionals, including
counsellors and psychotherapists, should also seek consent from the young
person themselves according to the law of Gillick competence, therefore valuing
the individual’s right to be autonomous and self-governing. A difficult ethical
dilemma can arise when consent has been provided yet the counsellor believes
that to share information would be contrary to promoting the client’s well-being.
It seems to me that whether the information was shared or not, the counsellor
could argue that he or she had made a decision that was supported by one or
more of the BACP’s ethical principles. Yet the impact on the client of sharing
or not sharing information would differ enormously. When ethical dilemmas such
as these arise, as they so often do, my foremost aim is to promote the clients’
wellbeing and protect them from harm. For me, these are the guiding principles
of my work and for my clients that is good-enough.

Where the previous BACP framework
contained ten personal moral qualities to which we were ‘strongly encouraged to aspire’, now there are eleven. Some have
been left out (competence and fairness) while others have been added (care,
diligence and identity). I think they are all worth considering, both individually
and jointly in supervision. They provide a solid framework within which clinical
issues can be considered. For example, I have supported supervisees in
considering how they can remain resilient in their practice without diminishing
their own needs, how they can deal with colleagues honestly and how they can
manage their fears and uncertainties in an often uncertain profession.

The Good Practice section
of the new ethical framework has had a major overhaul and is clearer, more comprehensive
and promotes greater inclusivity. We are no longer being told, in a somewhat
detached way, what practitioners should
do, but instead the statements read rather like a pledge: ‘We will work with
our clients… We will do all that we reasonably can… We will collaborate with
colleagues…’ This engenders a sense of ownership that should promote useful
self-reflection. There were a couple of statements that stood out for me as
particularly pertinent to my work with young people. For example; ‘We will…recognise when our knowledge of key aspects
of our client’s background, identity or lifestyle is inadequate and take steps
to inform ourselves from other sources where available and appropriate…’
(22f). I am forever being reminded of my inadequate knowledge about social
media, gaming, popular music, sexual practices and its accompanying terminology,
and I do my best to educate and inform myself. My Google search history makes for
fascinating reading! For example, a young person recently told me about the
pressure he felt under to maintain ‘streaks’ on Snapchat. I thought I knew what
Snapchat was, but what I hadn’t known is that a year ago the social media forum
introduced Snapstreak, which measures the number of days that you and a friend
have been exchanging Snap by adding a flame and a number next to their name. If
one person fails to respond the streak is broken, the flame dies and the number
returns to zero. The pressure comes from the competitive element of building
the longest streaks. So for the young person I spoke to, if he didn’t respond
to every message immediately, he felt responsible for letting his friends down
by destroying Snapstreaks built together over several months. Competition
abounds in adolescents’ lives and these things matter because they influence
their social identity. However, I continue to witness colleagues’ misperceptions
about the inherent dangers of ‘new’ apps such as Facebook and Snapchat that, in
their opinions, cause harm. Snapchat has been here for 5 years and Facebook has
been around for twelve; it’s old news, as is the fact that many of the
Association’s members remain uninterested and uninformed.

Another area where I have
felt compelled to inform myself is in relation to physical illness. I have no formal
medical training but have developed a decent understanding about conditions
such as cerebral palsy and hypermobility syndrome, because I’ve worked with
clients who have had these diagnoses and I needed to understand them.
Similarly, I know about the effects and side effects of common drugs such as
Risperidone, Sertraline, Quetiapine and Aripiprazole.
And I can pronounce them!While
working with a young man with testicular cancer I read lots about symptoms and
treatments so I could better understand what he was going through. Being
informed of the facts doesn’t replace getting to know what the condition feels
like for the individual, that’s always idiosyncratic, but it does provide a
shared language that helps us to connect.

My guess is that many people
will interpret this clause of the Good Practice guidelines in a different way,
perhaps focusing instead on culture, religion or, if we’re lucky, sexuality. At
a recent professionals meeting we discussed a young person who identified as
transgender and pansexual. Most were unfamiliar with the concepts. Some perceived
them as ‘fads’. There was a conversation about gender identity and bisexuality
being ‘all the rage’. I applaud the inclusion of the statement ‘we will… inform
ourselves’. My fear is that those colleagues with the most to learn do not know
what they do not know. I suppose it’s every other member’s responsibility to
give them a gentle nudge.

Another clause that stands
out to me is ‘We will ensure that ‘reasonable
care is taken to separate and maintain a distinction between our personal and
professional presence on social media…’ (33c). In my experience, the worst
offenders fall into one of two camps; they either use social media
indiscriminately, blurring the boundaries between personal and professional – Newsflash:
it’s not just young people who over-share – or they shy away from it completely.
I was commended recently on my ‘media presence’ by a counselling training
provider who had accessed my services via my professional website and who follows
me on Twitter. She spoke about the widespread reluctance amongst counselling
and psychotherapy professionals to make use of social media and her consequent difficulty
in making contact with any. I’m aware of this reluctance. At a training I
attended, one prominent facilitator proudly announced that he has no Internet
presence whatsoever! How does he get work? I use Twitter to share pertinent
reflections, links to my published work and newsworthy items from the world of
counselling and psychotherapy. I follow professional organisations such as BACP
and Therapy Today as well as a number of psychotherapists who I hold in high
esteem. It’s a way of keeping in contact, preserving my professional profile
and keeping my knowledge up to date; which is another of the professional
standards outlined in the BACP Good Practice guide. My website includes details
about my qualifications, experience and private practice. I’ve outlined my
therapeutic model and included a contract and referral form; all in line with
the BACP Ethical Framework. Rather than merely telling potential clients that I
abide by the Association’s professional standards, I use my website to
demonstrate how I do this. And I share nothing there or on Twitter that I
wouldn’t share in the therapy room. The social media forums I access for
personal use are separate and I’ve learnt to check the privacy settings
regularly to maintain this. If clients request to ‘friend’ me on Facebook I
remind them about the therapeutic boundaries that exist to protect us all, and
that this applies to the virtual world as well.

If you haven’t already reviewed
the new Ethical Framework then you should do it now. I also urge you to have a
notebook and pen to hand. Better still, examine the document with a supervisor or
colleague and initiate a dialogue. Don’t look at it as a dry, directive
document. Instead, transform each clause into a question and reflect on how it
applies to you and your clinical work. Really engage and be honest about your
practice. Think about the times when something went wrong, or could have done,
and use the framework to help you to consider how you would respond differently
if a similar dilemma arose in your work tomorrow. The revised Ethical Framework
won’t tell you what to do or alleviate your clinical responsibility, but it will
provide you with a scaffold, just as any good framework should.

Where Lunatics Prosper

A growing number of young boys are being referred to CAMHS because they are unable to concentrate, failing academically and have no impulse control.Jeanine Connor argues that computer games are partly to blame for a marked increase in young male aggression and age-inappropriate sexual behaviour.

The title of this piece is the tag-line from Grand Theft Auto (GTA) III (1), a console game marketed at young men aged eighteen and over. Regrettably, the appeal of this, and similar games, covers a much wider demographic and is the primary pursuit of many children as young as eight years old. One of the mainstays of this type of game is violence; injury and death is portrayed in graphic detail as dying bodies hurl through the air and bullets cut through flesh, splattering blood across the screen. The character in Call of Duty (2), for example, opens fire in a busy airport killing innocent bystanders in order to progress to the next level. I was informed of this by a boy of eleven who, reflecting on his hobby in a therapy session, told me; ‘I don’t know what I would do if I was ever in a real airport with a gun’. God forbid, I thought. The latest blockbuster in the Call of Duty series is Black Ops (3) which sold more than 7 million copies within 24 hours of going on sale. In this game, the marketing hype informs us, players are able to ‘turn down the blood and turn off the profanity to suit their needs’. There can be no argument that the amount of blood and profanity a child ‘needs’ is zero, yet the prepubescent boys who spend their free time playing these games seem most unlikely to censor them. Equally as concerning is the sexual content of many console games played regularly by young children. In GTA III the character acts out sexually explicit scenes. In GTA IV (4) he picks up prostitutes and selects from three levels of service; masturbation, fellatio, and full sexual intercourse. Many of the boys who access these games are still in junior school and spend several hours a day playing them in bedrooms, behind closed doors, often with their parent’s knowledge and consent. I wonder if these parents would be as consenting to their young sons watching pornographic films.

A recent study of ten and eleven year olds conducted by Bristol University found that playing computer games for more than two hours a day increases the risk of mental health problems by 60% (5). This is a scary statistic but, like most statistics, it does not really mean very much to most people. My own observation is that players of [most] console games are rewarded for action, speed and progressing to higher levels by fair means or foul [legal ‘cheats’ are readily available online]. I hear from countless parents and teachers about their children’s inability to concentrate, about their uncontrollability and about their academic failings. I wonder aloud about the link between their computer habits and observable behaviour. I also hear about children who are described as violent to siblings and peers, who use sexually explicit language and who seem devoid of empathy. I speak to children about their interests and learn that they enjoy games in which they are vicariously rewarded for killing and that the role of female characters is merely to provide visual and sexual gratification.

I hear the argument touted vociferously that there is no direct link between the playing of console games and violent behaviour, but my clinical experience highlights numerous risk factors. As with most experiences, context is paramount. Many of the children I work with have grown up in families where boundaries are, at best, permeable. Many have witnessed aggression and violence and have experienced trauma, neglect and abuse of all kinds. These children are twice as likely as those who are not deprived or disadvantaged to develop a formal mental illness. In order to escape their despicable realities, many of the children I meet in the consulting room have retreated into a fantasy world of console games. In doing so, they form identifications with fantasy characters who are fighters, killers and abusers, in order to defend against their own vulnerability. With a gun in their (virtual) hand and a (virtual) female companion to provide sexual gratification at the push of a button, these children can, at last, feel truly omnipotent.

Child and Adolescent Mental Health Services (CAMHS) are receiving a growing number of referrals of violent and aggressive boys who are unable to concentrate, are failing academically and have no impulse control. In many cases, the referrer is seeking a diagnosis of and treatment for Attention Deficit Hyperactivity Disorder (ADHD). A similar, yet distinct, type of referral relates to children who are described as destructive, aggressive, and lacking in empathy, obsessional, hyper-vigilant and overly-sensitive. The referrer in these instances is often seeking a diagnosis of Autistic Spectrum Disorder (ASD). In both types of referral, a mental health diagnosis is sought in order to explain the child’s behaviour and, in many cases, a drug to control it. And I can see why. These children present with the clinical symptoms learned by professionals by rote from diagnostic screening tools and manuals such as DSM-IV (6) or looked up on the Internet by baffled parents. I recognise and support the merits of thoughtful, accurate diagnosis and treatment, but to label a child in haste is tantamount to imposing one’s own version of reality onto an already identity-confused individual. To do so is, in effect, saying ‘I shall view you and define you in this particular way and completely ignore your own experience of who and what you are.’ (7). It is also worth noting that Fetal Alcohol Syndrome, a widely under-diagnosed condition, looks very much like ADHD and in some cases ASD. In my opinion, any mental health assessment is incomplete if we ignore the child’s family and environmental experiences. To do so may result in a neat diagnosis, but it is also likely to leave the child exposed to further risk and potentially irreversible damage.

I am lucky, as are the children whom I assess, in that I work as part of a multi-disciplinary team of mental health professionals. During thorough assessment, we have noticed remarkable similarities in the family backgrounds and experiences of the children I have begun to think of as ADHD-like and ASD-like. The majority of ADHD-like children we meet, predominantly latency aged boys, have witnessed domestic abuse and been allowed to play age-inappropriate console games. The same is true in many of the ASD-like children referred to our service. This suggestion is not the result of subjective, self-serving research; it is a clinical observation which has presented over time from the ordinary case-load of referrals made to an ordinary CAMHS service. My guess is that similar observations are being made in clinics up and down the UK.

What follows is a clinical case study which is an amalgamation of dozens of children I have assessed for therapy. It is presented as an amalgamation for two reasons; to maintain the anonymity of the children detailed and because their stories are so similar. Darnell is a nine year old boy referred to CAMHS for a mental health assessment by his GP. The referral letter states that Darnell meets every one of the criteria for ADHD and is so extreme in his presentation that a diagnosis is inevitable. Darnell is described as hyperactive and inattentive. He is alleged to bully his peers, particularly girls, with sexualised language and aggression. He cannot be left unattended with his younger sister, Jess who is four. He is failing academically and has been suspended from school on numerous occasions and faces permanent exclusion if his behaviour cannot be tamed.

At assessment, we met with Darnell, his mother and Jess. Mum was heavily pregnant and showing signs of bruising to her face. We were told that Darnell is uncontrollable and that he refuses to do as he is told; telling his mother he hates her and that she should ‘fuck off’ and is ‘a slag’. He has said that he wants to kill her and also that he wants to die. Darnell’s mother confided that ‘he has always been like this’ and that even as a baby he was ‘difficult’, whereas Jess is, and was, much easier. Jess did indeed remain calm and unusually quiet throughout the two hour assessment. Darnell sneered and groaned. He broke some of the toys and devoured a packet of tissues by chewing them up and spitting them out. We learnt that Darnell was an unplanned baby. His mother was eighteen and had been in a relationship with John, Darnell’s father, for only a few months when she discovered she was pregnant. We wondered if John had been supportive and were told that ‘he did what he could’ but that they lived separately with their own parents for most of the pregnancy until they moved into Social Services funded accommodation prior to Darnell’s birth. His mother told us that John drank a lot ‘because of stress’ and would sometimes become aggressive. He once punched her in the stomach when she was pregnant and she gave birth with a black eye. She believed that John loved her and wanted their baby. Following Darnell’s birth, the violence ‘got really bad’. The relationship ended when John drove their car, under the influence of drink and drugs and with baby Darnell and his mother as passengers, under a truck. She thought they would all die. John went to prison for ‘driving under the influence’ but she thought it was important to maintain contact between Darnell and his father and so regularly took him for prison visits in his early years.

Darnell’s mother began a relationship with John’s friend, Jason, who ‘was really supportive at first’ while John was in prison. But he raped her and she became pregnant with Jess, telling no-one the details of the conception. She has been in her current relationship with Jamie for eight months and he is the father of her unborn child. Jamie was described as ‘like a third child’ and Darnell’s mother admitted that they have heated arguments and sometimes ‘use each other as punch bags’ to ‘let off steam’. When I spoke to Darnell alone he told me that he hates Jamie because he is mean to his mum and he is lazy and won’t play football. Darnell has learnt that if he is naughty at school he gets to go home and that way he can make sure his mum is ok. Yesterday the Police came again because Jamie had hit his mum because he thinks the baby is not his. Darnell said he tried to be good because he is frightened he will be taken into care like his older brother, a child I had not been aware existed, but who I later learnt was in foster care due to emotional and physical neglect. I expressed my concern about Darnell’s situation, stating very clearly that it is not ok for grown-ups to hurt each other or to make children feel frightened. Darnell admitted that he sometimes feels sad, but ‘not frightened because I’m not gay!’ I asked Darnell what he likes to do when he isn’t at school and was given the inevitable response of ‘x-box’. Fearing the answer, I asked Darnell which games he likes to play. I noticed him become excited and animated for the first time during the assessment. He said he likes the GTA and COD games and had just got Black Ops for his ninth birthday. I commented on how lively his expressions had become and wondered aloud what it was that Darnell enjoyed about these games. He said simply, ‘sex and killing’.

‘Darnell’ is illustrative of countless young boys whose lives consist of real and virtual violence and who often present as ADHD-like. Their lives are messy, unsafe and without boundaries and so it should be no surprise that they present as chaotic, at risk and uncontrollable. These children ‘create havoc at home and school... as if they were spilling out all over the place’ (8). Children like Jess are also damaged by their experiences and remain at risk but, unlike Darnell, many of them go unnoticed. These children are compliant and expend their energy ensuring that there is no mess and no chaos as an antithesis to their messy and chaotic lives. They are often hyper-vigilant to noise and notice everything. As they get older they may switch off emotionally and end up in GP surgeries and CAMHS clinics presenting as ASD-like.

Children are damaged beyond measure by exposure to violent and sexual imagery and language; be it in the home or on the screen. Adults who allow this to happen are guilty of social and emotional neglect, or what has recently been termed ‘urban neglect through technology’ (8). Psychodynamic literature emphasises the importance of infant-caregiver attachment, yet for many children, early ‘care’ is provided by a screen portraying sex and violence. For many children, this provides a mirror to their external lives so that fantasy and reality become inextricably tangled. In the absence of a suitable father role model, the process of identity formation for pre-pubescent and adolescent boys becomes enmeshed with on-screen characters who are an exaggerated version of themselves (9). These boys crave ‘raw, loud and angry... because they need it to be strong enough to match and master their [own] anxiety and anger (10).

However, society is, on the whole, turning a collective blind-eye. Instead, the media spotlight highlights the potential impact of provocative clothing for young girls which, it is argued, leads to their premature sexualisation. Yet the spotlight has merely flashed over their male counterparts who, while their female peers play dress-up, are simulating oral sex and bloody violence. If this trend continues, trials for murder, rape, paedophilia and domestic abuse are more likely to draw attention to female attire than male console game addiction. This feared future will indeed be a place ‘where lunatics prosper’ (1).

In this article I aim to address three key questions that have been recently in my mind, which are: 1. What are adults choosing to ignore when they deem something a child tells them to be a lie? 2. What are children trying to tell us when they tell us a lie? 3. How can psychodynamically informed thinking help us to reflect upon the meaning of children’s so-called lies?

A theme has developed in my psychodynamic practice with children and adolescents; that I am frequently ‘reminded’ by parents, carers, teachers and social workers that what my young patients have told me is a lie. These children have been accused (outside of therapy) of ‘making it up’ or of ‘attention-seeking’ and I have been assigned the wholly inappropriate task of getting them to stop. The baseline for my thinking about this is that children need us to hear what they say. Furthermore, they need us to help them to think about, rather than punish, nullify or prohibit, all forms of communication if they are to find the courage to speak to us. I think this is true whoever a child confides in, be it therapist, teacher or parent. It is a uniquely valuable experience to be thought about and thought with in the absence of judgement or bias; an experience which, of course, is fundamental to therapy. But I believe that any adult, whether in a professional or parental role, can enhance the channels of communication with the young people in their care by taking on board some of what psychodynamic thinking has taught us.

Fantasy – v – lies

Our aim in working with young people psychodynamically is to help them to unravel the many and varied realities they bring to therapy. These realities have both physical and psychological manifestations and they are carried consciously and unconsciously into the therapeutic space. My use of the term realities is intentional as I would argue that ‘lies’, in the traditional sense, never exist in the therapy room. My patients know, perhaps unconsciously, that I am not an arbiter of the truth (although I am often a detective!) and I think that this allows them the freedom to express their real and fantasised experiences and to explore them with a mindful ‘other’. Therapists might think about patient’s fantasies, or unconscious phantasies as Melanie Klein (1) called them, but in my view these are quite distinct from lies. I think that fantasies are similar to dreams in that they allow latent desires, fears and anxieties to become manifest in a more manageable form. Play, drawing and creative writing are used by children to express themselves in a way which words sometimes fail to do. These are more tangible vehicles for carrying unconscious fantasies into the realm of conscious awareness and they are valuable forms of communication about internal worlds. Many adults realise this, mostly at an unconscious level, but I think that this awareness can be used as a basis for thinking about so-called ‘lies’. For example, it would be extremely unlikely, even in the non-therapeutic world, for a young person recounting their dream to be branded a liar or for a child’s painting to be labelled a lie. If we think about children’s fantasies in the same way as we think about their other forms of unconscious communication it seems just as ludicrous, I hope, to judge them as lies. Just as the child’s drawing or dream symbolises and communicates something about their internal world, the young person’s narrative must also contain a form or fragment of reality which originates in real, rather than imagined, experience. For that reason it deserves to be listened to, accepted and thought about rather than labelled a lie.

Reality – v – lies

In my experience, what has been branded a lie often contains elements of current or historical abuse. In these circumstances the obvious hypothesis seems to be that doubt is a more comfortable position for the disbelieving adult to take up than belief in the unbearable-ness of child abuse. Furthermore, in deciding that a child’s allegation of abuse is a lie, the adult (or system) can avoid thinking about it further because in their mind it did not happen. This is a classic illustration of denial as a form of ego defence. I would also suggest that denying the abuse is a way that adults avoid becoming enmeshed in it themselves. The varied ways in which unconscious anxieties and defences can get played out in disbelieving adults is illustrated by three vignettes taken from my clinical work with young people.

A seventeen year old female patient, who I will call Yolanda, made an allegation of rape against a male peer at college. The boy denied it and was believed by both sets of parents, staff and the police. He was a ‘good student’ while Yolanda was labelled a ‘drama queen’. By believing the ‘good’ boy, the system maintained an effective split between bad/abuse and good/non-abuse and positioned itself with the latter. No further action was taken and, more significantly I think, the awfulness of peer sexual abuse was eradicated from the minds of the system. However, Yolanda continued to suffer terrifying flashbacks of the rape in her nightmares and at college where, unsurprisingly, her behaviour became more unmanageable until she was excluded. In my view, her removal from college is a further illustration of an attempt to split off the ‘bad’ parts believed to be located in her (abuse and lies) in order to protect the ‘good’ institution. An alternative hypothesis is that her exclusion could be seen as a re-enactment whereby the system unconsciously identifies with the abuser and therefore prolongs, highlights and draws attention to Yolanda’s suffering.

As Yolanda’s therapist, I had to bear in mind all of the ‘realities’ being revealed to me by my patient and the wider system. Notably, my responsibility was not to get to the truth but to bear witness to whatever my patient brought to her sessions, consciously and unconsciously, in the form of dreams, memories or lived experiences. Maintaining my position alongside rather than being drawn in was not easy but it afforded me the emotional distance and perspective my patient needed. Alice Miller (2) suggests that a therapist should ‘devote his full attention as a spectator to the drama, without jumping onto the stage and joining in the act’. It was the experience of a thoughtful and attentive ‘spectator’, I think, that enabled Yolanda to become aware of historical sexual abuse memories which were awakened by her recent experience. Clinical research (3) supports the hypothesis that memory for historical trauma can become entangled with memories for recent trauma. Yolanda’s childhood sexual abuse was brought gradually into conscious awareness and worked through in therapy until she was ready to make a full disclosure. Without the experience of having someone believe her experiences, the repressed memories of what happened to Yolanda as a child are likely to have continued to haunt her into adulthood.

An alternative reality

Also pertinent was the shift in attitude of the professional system during my work with Yolanda. At the outset, the preoccupation was with the ‘lies’ about the rape and how best to manage (i.e. change) Yolanda’s behaviour. In multi-agency meetings I was able to feedback into the system my observations of Yolanda’s emerging depression as well as her ambivalence about coming to terms with her experiences. While respecting confidentiality, I shared the idea that creating and/or maintaining difficulties in the present can provide a focus for feelings which belong in the past. I was able to share my thinking, at a theoretical level, that memories of historical trauma can become entangled with those of recent experience, and that therapy can help to untangle and make sense of this. By sharing my thoughts in this way, the confidentiality of Yolanda’s therapy was maintained and the system gradually became more reflective. We wondered together about what the ‘rape’ might represent for Yolanda which encouraged thoughtful rather than spontaneous responses. Eventually, a collective realisation was reached that what mattered more than the truth of theexternal reality was an acknowledgement of Yolanda’s internal reality. This insight raised awareness about the unbearable-ness of Yolanda’s experience in the here-and-now and enabled the system to reflect upon it as something real. The shift from arbiter of truth to thoughtful spectator was communicated unconsciously and, I believe, was fundamental to Yolanda’s subsequent disclosure of historical abuse; which, interestingly, was believed unanimously.

The disbelieving child

The second vignette contains an example of a different kind of ‘lie’; one which appears to symbolise the disbelieving part of the child located within a disbelieving system. Morrie was a fourteen-year-old boy who had been taken into care aged four after enduring incestuous sexual abuse. We had been working together for a year when his foster-carer found a note, written by Morrie, claiming that a same aged boy had forced him to perform oral sex. No-one in the professional system believed this was true and I was warned by his social worker that ‘while he might have the face of an angel, he lies like the devil’. As with Yolanda, I was informed about the incident so that I could ‘address the lying’.

One of the worrying things about Morrie’s experience was the inability of the system to think about it. Social services disbelieved him; the police colluded and dismissed his allegation; school excluded him (to ‘protect [the other boy] from further untrue accusations’) and his carers went on holiday leaving him in respite care for a week following discovery of the note. The message being communicated to Morrie was that he was a liar, the bad one, the ‘devil’ child and that nobody wanted to listen to him. Paramount in my mind was Morrie’s unresolved childhood abuse and how it might fit with his current experience. I was mindful that history might be repeating itself in more ways than one; that Morrie could have suffered further abuse and that, in the very least, he was re-experiencing disbelief and rejection from the adults responsible for his care. Evidence for the possibility of re-enactment was also present in the system, illustrated by a teacher’s flippant remark that Morrie was ‘once a victim, always a victim’ suggesting that, at least unconsciously, she believed that Morrie had experienced further abuse.

It seemed vital for me to provide Morrie with a space to think alongside a thinkingother. The next time we met he demonstrated his availability for symbolic thinking, quite beautifully, in the sand tray. The sand was damp and had formed lumps which Morrie crumbled between his fingers. He asked me to help ‘breakdown the hard bits’ and offered me a spade so as not to get my hands dirty. I commented that he seemed to want my help but also that he had a desire to protect me from the hard and disgusting bits. In his own time and without prompting he told me that he had been ‘forced to do something’ and in lieu of naming the sex act he gagged and told me it had made him feel sick. He said he wanted it to stay a secret because thinking about it made him want to vomit. I think this feeling was mirrored in the system which was unable to acknowledge something as sickening as forced homosexual activity.

Morrie told me he had coped with what happened by pushing it to the side of his head ‘where the bad stuff is’ so that he could just know about the ‘good stuff’. He could not elaborate but I noticed that one half of the sand tray now contained only fine sand without lumps and I commented that the ‘hard bits’ and ‘bad stuff’ had been separated to the other side. Morrie said this was what it was like inside his head but that we would not be able to get rid of it all today. Morrie’s sand play provided a concrete illustration of his attempt to split off the trauma as well as, perhaps, the system’s attempt to deny it. It also seemed to flag up the other ‘bad stuff’ which Morrie was unable to consciously acknowledge.

In our work together, neither the historical sexual abuse nor Morrie’s recent experience was named and his motives and realities were never questioned. Instead, a containing space was provided in which he could play and communicate in ways which felt bearable, which I facilitated, encouraged and cautiously interpreted. What I witnessed was what Winnicott (4) described as the ‘space between inner world and outer reality [which] creates the possibility for playing and for the filling of the space with symbols’. In contrast, the wider system of school, social services and fostering, remained fixed in the belief that Morrie was lying. They questioned him repeatedly and when he was unable to recall specific details they called him a liar. They interpreted his anxiety, doubt and confusion as confirmation that he could not be trusted. In contrast to the professional network around Yolanda, this system refused to engage in any meaningful thinking about Morrie’s experiences with me or with him. My wondering about the timing of the disclosure, in context of the imminent anniversary of his removal from abusive birth parents, was dismissed as coincidence. My suggestion that Morrie’s depiction of oral sex with a peer was likely to contain at least some reality and that his normal adolescent sexual development was certain to be tainted by his early sexually abusive experiences fell on deaf ears.

Evidence suggests that motivation to remember is a key component in memory and that in ‘a sexual or physical abuse situation, neither the situation itself nor the adult involved would encourage the motivation to remember’ (5). Further clinical research suggests that doubt and confusion is evidence of attempts to recall a true memory rather than of inventing a lie (6). The system rejected all my attempts to help them to think in this way and, like Morrie, I was ignored and dismissed. As concerning (and frustrating) as this experience was, it was also a powerful re-enactment of an abusive system which repeated and perpetuated Morrie’s experience of being abused.

The overt lie

The final vignette provides an illustration of a child who, in contrast to the first two examples, told lies which were obvious and easily falsifiable. Harry was referred for psychotherapy aged ten following concerns about his behaviour at home and school in the context of possible child protection. He disclosed that his mother was seriously ill with an incurable disease that caused her to lapse in and out of coma. His father did not allow him to visit her in the hospital which he was finding incredibly distressing, particularly as her birthday was approaching and he wanted to take her some flowers. Harry’s narrative was elaborate and included specific details about his mother’s illness, the hospital and the staff caring for her. He said that she became ill when he was five years old, just after the birth of his sister. Harry remembers there being lots of arguments between his parents and that occasionally these became violent. Soon after this his mother was diagnosed with terminal cancer and spent time in and out of hospital so that he rarely saw her.

Taken at face value, Harry’s story is a sophisticated and somewhat disturbing lie. However, it is also a powerful communication about his experience of life and family relationships. It states undoubtedly that things changed for Harry when he was five years old. It is known from the history that this coincided with the two most significant events in his short life; starting school and the birth of his sibling. Thought about in this context, Harry’s claim that his mother was diagnosed with a terminal disease illustrates his overwhelming sense that he had lost her and that she would be gone forever. It is true that Harry’s mother went into hospital when he was five; to give birth to his sister. This knowledge is likely to have been very frightening for little Harry, particularly if his father, as Harry claims, did not allow him to visit her. We can imagine how confusing it can be for children to reconcile their idea of hospitals as places where the sick go to get better, with the notion that people go there to collect babies in order to usurp older siblings! Harry’s internal world seems to have become a tangle of hospitals, illness, babies and loss. His claim that his mother contracted an ‘incurable disease’ and slipped ‘in and out of coma’ seems symbolic of his internal reality. If, as hypothesised, his mother’s ‘disease’ represents pregnancy, then attending to her baby could be experienced by Harry as an abandonment so catastrophic it feels as if she were dead to him, that is ‘in and out of coma’.

Psychodynamic theory tells us that, at some level, even very young children associate pregnancy and birth with the primal scene and that this is often experienced as aggressive and frightening. Harry recalls violent arguments between his parents and perhaps associates this with the sexual act which produced the baby. From an Oedipal perspective, Harry may feel some sense of responsibility, hence his childish attempts at reparation in the giving of flowers. However, it is Harry’s father who is vilified; he is responsible for the arrival of baby, for making his mother ill and ultimately for standing between Harry and his mother. It was possible, over time, for Harry to work through his overwhelming feelings of love, hate and rejection in therapy. His emotional responses were undoubtedly real, his narrative was simply a vehicle used to carry them into conscious awareness.

The three young people described in this article had all been accused of telling lies. What I discovered in working with them was that they were confused, frightened and traumatised; that they had something important to communicate; and that they needed the opportunity to think alongside a mindful spectator. Meeting them has been a privilege. I hope that their experiences will encourage professionals to employ a more psychodynamically informed way of thinking about young people’s communications and avoid at all costs the temptation to dismiss them as lies.

References

1. Klein, M. (1955) The psycho-analytic play technique: Its history and significance. In Klein, Melanie, Heimann, Paula, and Money-Kyrle, Roger E. (Eds.), New directions in psycho-analysis, Tavistock Publications, London